Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Mat-Su Regional Medical Center
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Physical Environment & Infection Control Rounds - OR Areas 2013
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EC.04.01.01.14.a
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Surveyed By:
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Surveyed By:
PATIENT SAFETY MANAGEMENT
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Are corridors kept clear to allow adequate space for:
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A) Patients, visitors and staff to walk safely?
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B) Carts, wheelchairs, equipment and beds to pass with
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C) Are floors clear and slip-resistant finishes in place?
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Are medication and sharps secured and locked:
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A) Are medication rooms and anesthesia carts locked when not attended?
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B) Are needles and syringes locked when unattended?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
FIRE SAFETY MANAGEMENT
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Are the means of egress corridors/exit doors:
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A) Clearly and correctly marked for EXIT, including when fire doors are closed?
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B) Are lights in exit signs functional?
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C) Clear of any obstructions/equipment?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Are all fire extinguishers:
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A) Clearly marked for identification and installed at correct height (maximum of sixty inches)?
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B) Inspection tags current? (monthly and annual)
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C) Safety seals intact and in place?
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D) Accessible, with three foot clearance in all directions?
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E) Within seventy five feet in any direction in the area?
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F) Are there CO2 fire extinguisher in place for use in operating rooms?
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G)Is there a roll of orange masking tape in the extinguisher box? (main corridors only)
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Are the fire alarm pull stations:
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A) Accessible, with three foot clearance in all directions?
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B) In good condition, free from tampering and glass bar in place where applicable?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Are combustible materials: cardboard, boxes, paper, linen, wastes)
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A) Stored in proper containers? (32 gallons or less)
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B) Kept to a minimum for daily use in department?
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C) Properly labeled and identified?
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D) Are alcohol-based hand rubs properly mounted from electrical devices? (6 inches from device)
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Compressed gases and trash/linen chutes:
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A) Are there less than 12 E-tanks (300 cu ft, oxygen) stored in the smoke compartment?
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B) Where compressed gas storage exceeds 300 cu ft, is there a designated, protected storage room?
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C) Full and empty O2 cylinders in storage are segregated? (Full & Empty)
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Fire Building Systems, components and Safety Practices:
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A) Are all doors free from being propped, wedged or held open in any way?
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B) Are all doorways clear to close properly?
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C) Do patient room doors latch when closed?
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D) Do fire and stairwell doors latch positively and maintain closure?
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E) Do door coordinators function properly where installed?
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F) Are all doors physically in good condition to prevent the spread of smoke or fire?
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G) Are rooms used as patient sleeping rooms free of deadbolt locks?
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H) Is the area free from any evidence of smoking in the area?
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I) Are furnishing and decorations fire-rated?
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J) Is there at least 18 inches of clearance between storage and sprinkler heads?
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K) Are escutcheons in place on sprinkler heads and are they clean and free of debris?
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L) Do patient privacy curtains have at least an 18 inches mesh top?
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M) Is the area free from portable heaters and heating devices? (No heaters in the hospital per CHS)
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
SAFETY MANAGEMENT
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Are the floors in hallways:
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A) In good physical condition?
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B) Clean and dry?
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C) Free from trip/fall hazards?
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D) Wet floor signs used properly?
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E) Carpet free of wrinkles or tears?
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F) Free from obstruction? ( wires/cords etc.)
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Are the walls:
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A) Painted and in good physical condition? (Free of holes or water damage)
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B) Free from exposed wiring of any kind?
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C) Are electrical covers/plates in place and in good condition?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Are ceiling tiles:
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A) In place and in good condition?
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B) Free of dirt, mold, dust and stains?
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C) Free from evidence of water stains?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
INFECTION CONTROL MANAGEMENT
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Infection Control Practices:
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A) Are all sharps containers less than 2/3 full?
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B) Is clean linen kept covered?
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C) Is the clean linen physically and clearly separated from the dirty linen?
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D) Are all medications dated and labeled?
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E) Any outdated medication/supplies found?
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F) Are refrigerators labeled to identify Patient,Staff and Medication use?
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G) Are all foods dated and labeled?
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H) Are current temperature logs in place and readily available?
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I) Are cardboard boxes off the floor, with no corrugated shipping containers present?
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J) Is there evidence of BLOOD BORNE PATHOGEN PRECAUTION procedures in place? (gloves, masks, gowns, separation of waste, etc.)
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K) Is personal protective equipment readily available for use?
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L) Are the cabinets under the sinks free from storage of clean supplies/equipment?
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M) Are all sharps storage areas kept locked at all times?
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N) Have all product recalls been corrected by department?
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O) Are floors, fixtures and equipment in clean condition?
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P) Are patient rooms and bathrooms clean and suitable for patient care?
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Q) Are emergency showers and eye washes tested?
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R) Are current temperature logs in place and readily available on all blanket warmers? Are temperatures within range for blanket warmers (<130) and fluid warmers (<110)?
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S) Are carts and transport equipment free of dirt, rust and corrosion?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
HAZARDOUS MATERIAL AND WASTE MANAGEMENT
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Hazardous chemicals used in the area:
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A) Are janitor closets and other rooms with chemicals secured and stored correctly? (flammables, corrosives, etc.)
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B) Labeled correctly?
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C) Disposed of correctly? (Are there procedures for disposal?)
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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MSDS Manual in the Area:
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A) Have the department inventory (online) been updated within the past 12 months?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Medical Waste:
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A) Stored in properly labeled bags and containers?
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B) Properly stored and disposed of?
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C) Stored and segregated appropriately?
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D) Are bio-hazardous waste bulk storage areas secured, except to essential personnel?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
MEDICAL EQUIPMENT MANAGEMENT
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A) Are the inspection tags current with date of next inspection?
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B) Is clean equipment identified and stored properly?
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C) Are crash carts or carts with sharps and meds locked?
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E) Are crash cart logs documented consistently?
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F) Are medical equipment consumables (defib, pads, etc.) within expiration dates?
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G) List two (2) equipment inventory tag numbers and verify that equipment information is correct and inspections are current.
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H) Are daily air removal tests (DART) performed on sterilizers and do records show compliant test results?
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I) Are daily biological tests performed on sterilizers and do records show compliant test results?
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J) Are sterilizer records on file for each load?
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K) Are integrator tests on file for each flash load and do records show compliant test results?
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L) Are PM records for sterilizers current and is equipment in good condition?
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M) Is there a current list of scope in SPD?
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N) Are scopes stored per policy? Clean area and 6in off the ground or in a cabinet
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M) Are PM records for sterilizers current and is equipment in good condition?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
UTILITY MANAGEMENT
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Are emergency power outlets:
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A) Clearly marked by red covers and outlets?
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B) Being used for critical equipment only?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Electrical panels and devices:
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A) Are breakers in distribution panels labeled?
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B) Are mechanical/electrical rooms or exposed distribution panels kept locked, except to essential personnel?
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C) Are all covers free from damage, securely in place?
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D) Are waiting rooms provided with tamper-resistant outlets?
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E) In the area free of extension cords and multi plug-in outlet strips? (Patient care area only )
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Are medical gas zone and main valves:
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A) Marked to identify the area served?
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B) Are the valves accessible for immediate access? And not blocked?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Are plumbing systems:
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A) Autoclaves free of leaks from supply, drain or splashing?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Temperature and humidity:
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A) Is temperature and humidity monitored in each OR and areas where anesthetic gases are administered?
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B) Are temperatures maintained between 68 and 73 degrees?
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C) Are relative humidity levels maintained between 35 and 60 percent?
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D) Have appropriate actions been documented when readings are outside of parameters?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Area pressures:
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A) Are all of the OR positive pressure to corridors?
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B) Is the SPD clean storage positive pressure to the corridor?
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C) Is the scope storage area positive pressure to adjoining rooms and or corridor?
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Have appropriate actions been documented when readings are outside of parameters?
SECURITY MANAGEMENT
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SECURITY
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A) Are all employees wearing identification badges in plain view?
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B) Are all computer rooms locked except to essential personnel?
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C) Are all computers that are not in use - logged out?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
EMERGENCY MANAGEMENT
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EOP
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A) Is the department emergency lighting box locked?
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B) Are the Emergency Procedures flip charts easily accessible?
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Deficiency
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Responsible Person for Addressing Deficiency:
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Date Corrected:
HAZARDOUS AREAS - (LS 19.3.5.4)
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Soiled Utility Rooms and Storage Rooms >50 Square Feet (Example 5X10)
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A) Clean, neat and orderly?
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B) Items stored greater than 18 inches from fire sprinklers, unless fixed shelving against the wall?
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C) Rooms are constructed as hazardous areas (i.e. 1 hour fire rated or smoke resistive and sprinklered)?
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D) Do doors to Hazardous Areas have automatic closers?
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E) Do doors to corridors and rated rooms positively latch?
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Deficiency
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Responsible Person for Addressing Deficiency:
STAFF QUESTIONS: 1 (Must Interview a minimum of one staff member)
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Staff Member Job Title:
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FIRE SAFETY MANAGEMENT
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A) What does R.A.C.E stand for? Rescue, Alarm, Confine, Extinguish or Evacuate
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B) How do you alert everyone that there is a fire? Dial 6999 and have the operator announce Code Red and the location - or Pull a fire alarm box
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C) When was your last time you participate in a OR fire drill and or training. (Should be annually)
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SAFETY MANAGEMENT
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A) What is the most important thing that you can do to prevent the spread of infection? (Hand Washing)
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B) What equipment should employees wear while caring for T.B. patients? (N95 Mask or Orange Duck Bill or PAPR)
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C) What are the Standard Precautions? (Guidelines to follow to prevent the spread of infection. They have to do with PPE)
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D) Do you know where to find a current copy of the EOC/Safety manual online? ( On the Intranet Home page. Click on the EOC Safety Manual link)
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HAZARDOUS MATERIALS & WASTE:
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A) What is a MSDS? (Safety Precautions, hazards, and PPE to be used)
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B) Can staff explain how to obtain MSDS information? (link on the Intranet Home Page)
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C) Can staff explain the code for a large HazMat spill? (Code Orange)
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MEDICAL EQUIPMENT:
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A) If a piece of medical equipment fails on a patient, you should? ( Call your supervisor, remove it from service (keep all items like disposables), place an out of serviced; slip on it, complete; submit an event report to Risk Management)
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B) Can staff describe how they know if equipment if safe for use? ( Look at the Biomed service sticker and note the date.)
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C) Can staff explain emergency procedures for life-support equipment? ( Describe what they should do for various life support equipment failures).
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UTILITIES:
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A) Can staff describe who is authorized to shut off medical gases in the event of an emergency? (Resp. Therapy, Charge Nurse)
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SECURITY:
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A) Can staff explain the procedure to get help in the event of a security emergency (i.e. gunman, active shooter, and hostage)? (Dial 6999 & Code Silver called with a location)
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B) Can staff explain their role to get help with an uncontrollable person? ( Dial 6999 & have operator call a Code Strong)
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D) Can staff explain where to go and what to do when a Code Pink is called? ( Should know what exit their department is assigned to cover during a Code Pink.)
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E) Are security measures in place for the OR and can staff explain their role in providing security for patients?
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EMERGENCY MANAGEMENT:
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A) What is the code for disaster that will activate our Emergency Management Plan? (Code Black)
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B) Does staff know where to find a copy of the Emergency Operation Plan? (On the Intranet Home page. Click on the EOC Safety Manual link)
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C) If a building evacuation is announced, what would you do and where is your staging area? (Should know their departments staging area. (Nursing Department s Only)
STAFF QUESTIONS: 2
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Staff Member Job Title:
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FIRE SAFETY MANAGEMENT
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A) What does R.A.C.E stand for? (Rescue, Alarm, Confine, Extinguish or Evacuate)
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B) How do you alert everyone that there is a fire? Dial 6999 and have the operator announce Code Red and the location - or Pull a fire alarm box
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C) When was your last time you participate in a OR fire drill and or training. (Should be annually)
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SAFETY MANAGEMENT
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A) What is the most important thing that you can do to prevent the spread of infection? (Hand Washing)
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B) What equipment should employees wear while caring for T.B. patients? (N95 Mask or Orange Duck Bill or PAPR)
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C) What are the Standard Precautions? (Guidelines to follow to prevent the spread of infection. They have to do with PPE)
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D) Do you know where to find a current copy of the EOC/Safety manual online?(On the Intranet Home page. Click on the EOC Safety Manual link)
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HAZARDOUS MATERIALS & WASTE:
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A) What is a MSDS? (Safety Precautions, hazards, and PPE to be used)
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B) Can staff explain how to obtain MSDS information? (link on the Intranet Home Page)
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C) Can staff explain the code for a large HazMat spill? (Code Orange)
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MEDICAL EQUIPMENT:
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A) If a piece of medical equipment fails on a patient, you should? Call your supervisor, remove it from service (keep all items like disposables), place an &;out of serviced; slip on it, complete; submit an event report to Risk Management
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B) Can staff describe how they know if equipment if safe for use? ( Look at the Biomed service sticker and note the date.)
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C) Can staff explain emergency procedures for life-support equipment? (Describe what they should do for various life support equipment failures.)
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UTILITIES:
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A) Can staff describe who is authorized to shut off medical gases in the event of an emergency? ( Resp. Therapy, Charge Nurse )
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SECURITY:
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A) Can staff explain the procedure to get help in the event of a security emergency (i.e. gunman, active shooter, and hostage)? (Dial 6999 & Code Silver called with a location)
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B) Can staff explain their role to get help with an uncontrollable person? (Dial 6999 & have operator call a Code Strong)
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C) Can staff explain where to go and what to do when a Code Pink is called? (Should know what exit their department is assigned to cover during a Code Pink.)
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D) Are security measures in place for the OR and can staff explain their role in providing security for patients?
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EMERGENCY MANAGEMENT:
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A) What is the code for disaster that will activate our Emergency Management Plan? (Code Black)
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B) Does staff know where to find a copy of the Emergency Operation Plan? (On the Intranet Home page. Click on the EOC Safety Manual link)
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C) If a building evacuation is announced, what would you do and where is your staging area? (Should know their departments staging area. (Nursing Department s Only)
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Comments/Observations
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Responsible Person for Addressing Deficiency:
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Date Corrected:
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Department Director or Representative:
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Lead Surveyor:
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